Differing Diagnosis and Explanations for Back Pain.

Read this section on Psychosocial Yellow Flags first.

Patients with back pain who come to see me have often seen someone else first.

Maybe they saw their doctor, possibly a surgeon.
Many will have paid to see a chiropractor, osteopath or physiotherapist in a private clinic.
They may have family members with a similar problem or have discussed their problem with friends who have it.
Very often they will have been given different diagnosis and different explanations for their pain.

maze

There is nothing worse than having several people disagree on what is the matter with your back. It leads to anxiety and a loss of trust which in turn leads to more anxiety and fear. Its not deliberate, it’s a fact that the diagnosis of low back problems is dependant on what you tell the clinician and on certain clinical tests which are not always totally reliable. Some recent studies demonstrate this:

”The problem is rooted in the clinician's strong dependency on reported pain, which may not always be a reliable source of objective information”(1)

The impact of misdiagnosis has been studied (2) and shows an interesting finding. When someone is given different diagnoses the person suffering back problems becomes more certain that the doctors have it wrong and they know the answer, they become more attached to their pre existing beliefs about what is causing the problem. This may not be a problem unless the beliefs lead to unhelpful behaviours which are going to cause more problems e.g. fear avoidance and catastrophising.

I have had many discussions with patients who say something like this…

“My doctor said it was sciatica, and then the chiropractor said my back was out because my legs were different lengths and I had a rotated pelvis. X-rays show something different again, wear and tear, and now you’re saying its simple lower back pain and I should become more active.

I don’t trust that any of you know what is really wrong with me. It must be serious if you can’t agree and I’m not reassured any of you know what you are talking about. I’m going to be careful and avoid anything that makes my pain worse until I finally have an answer and have really got to the bottom of this.”

answers

The guide to assessing psychosocial yellow flags includes these experiences which make disability from back problems more likely:

Health professional sanctioning disability, not providing advice or treatment that will improve day to day living or function
Experience of conflicting diagnoses or explanations for back pain, resulting in confusion
Dramatisation of the back problem by health professionals producing dependency on treatment and health professionals continuing to provide passive treatment (passive treatments are things that someone does to you rather than active things you do for yourself)
Number of times visited health professional in last year (excluding the present episode)
Expectation of a ‘techno-fix’, e.g., requests to treat as if body were a machine
Lack of satisfaction with previous treatment for back problems
Advice to withdraw from job

References

1.Gracovetsky, S. A., et al. "The impact of inefficient clinical diagnosis on the cost of managing low back pain." Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management 17.3 (1997): 21-31.

2.May, C. R., M. J. Rose, and F. C. Johnstone. "Dealing with doubt How patients account for non-specific chronic low back pain." Journal of psychosomatic research 49.4 (2000): 223-25.